Clinical pearls for the shoulder/arm exam and the treatment. What is seeing youare you seeing it

Transcription

1 Clinical pearls for the shoulder/arm exam and the treatment What is seeing youare you seeing it

2 W. Ben Kibler, MD Medical director

3 Case 1 18 y/o R hand dominant high school pitcher, with 6 week hx gradual onset of anterior shoulder pain while pitching in season. Sore in cocking to acceleration and at ball release, no click or pop. Decreased velocity and endurance. No pain at night or in other activities. PT- no relief. Dx- impingement> surgery

4 Case 2 19 y/o R tennis player- chronic pain in shoulder during, after play. Pain localized to posterior joint line and lateral acromion, worse in cocking and ball impact. Also mild episodic back pain, does not keep him from playing. PT including modalities, rubber tubing, and massage gives no relief. Injection of unknown type gave no relief

5 Case 3 45 y.o. worker, chronic (L) shoulder pain, worse with overhead motion, decreased use over last 6 mos, painful arc, weakness. PT- no relief, injection- short term benefit. Dx- impingement- surgery

6 Case 4 20 y.o college pitcher, 2 mo pain (L) elbow, no acute injury, decreased velocity/ location, ball release, no swelling, no neuro sx, elbow exercises, modalities- no relief

7 HANAVAN MODEL 1 BODY AS A SYSTEM 8 9 OF LINKS (SEGMENTS) Adapted from Hanavan, EP. Mathematical Model of the Human Body. Wright-Patterson Air Force Base, Ohio, 1964, AMRL-TR,

8 Kinetic chain Sequenced coordination of activation- body segments Kinematic- body motions Kinetic- force development Kinetic- general term for both activation chains

9 Kinetic chain Purposes- efficient: Force development Sequenced motions Force transfer Joint protection Prox stability >distal mobility

10 THE KINETIC CHAIN F O R C E Shoulder Trunk and Back Legs Wrist Elbow 0 TIME Adapted From Groppel

11 Kinetic Chain Body as a multi-segmented mechanism 244 possible DOF multiple possible pathways Task specific requirements Bernstein s problem

12 Kinetic Chain Dec. DOF to efficiently accomplish tasks Develop motions Apply loads Muscle activations: force generation, joint stability

13 Kinetic Chain Closed system for force production/transfer Alterations in one area require compensations from other areas to maintain same output/progression

14 What is seeing you Leg/hip- flexibility/strength/ injury- 50% Core stability/strength- 65% Scapular dyskinesis- 90% GIRD, GERD, TROMD- 90% Altered anatomy- 100%

15 What is seeing you Standardized approach- rule in/rule out all factors Screening exam tests Detailed evaluation- (+) tests Comprehensive information

16 Shoulder rotation, flexibility, strength Internal derangement Scapular dyskinesis evaluation Leg stability series Hip rotation Plank Knee stability Ankle ROM

17 Hip, leg, core Ankle ROM Knee ROM, P-F, meniscus 1 leg stability- stance/squat HIP ROM- ER, IR 3 way core stability

18 Scapular dyskinesis Position at rest Motion- flexion/extension Low row strength Flexibility- pec minor, lat Corrective tests- SAT, SRT

19 Shoulder joint IR- scapula stable ER- arm neutral, pronated Rotator cuff- scapula stable AC joint stability Joint- labrum, rot cuff, biceps, instability

20 Conclusions Kinetic chain- mechanism by which coordination of the multiple segments for specific tasks is achieved Body works as a unit Kinetic chain framework

21 Conclusions Body fails as a unit Patterns of failure Catch up, compensations Victims and culprits Overview, screening, detailed exam

22 Case 1 18 y/o R hand dominant high school pitcher, with 6 week hx gradual onset of anterior shoulder pain while pitching in season. Sore in cocking to acceleration and at ball release, no click or pop. Decreased velocity and endurance. No pain at night or in other activities. (+) Neer, Hawkins sign Weak supraspinatus in forward flexion, empty can GIRD 35 degrees, (-) labral testing, (-) instability, sulcus (+) SAT, SRT X-ray (-)

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24 Case 2 19 y/o R hand dominant college tennis player with season long pain in shoulder and back. Worse while playing also hurts after play. Pain localized to posterior joint line and lateral acromion, worse in cocking and ball impact. Also noted some mild back pain which seems to come and go, does not keep him from playing. PT including modalities, rubber tubing, and massage gives no relief. Injection of unknown type gave no relief (+) Neer, Hawkins sign, (+) painful arc Weak supraspinatus/infraspinatus (+) M-DLS with (+) SRT, (-) anterior instability GIRD 45 deg. With scapular wind-up, Type I/III scapular dyskinesis Lumbar lordosis, (+) single leg stability w/ Trendelenburg Non-contrast MRI (-)

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26 Case 3 45 y.o. worker, chronic (L) shoulder pain, worse with overhead motion, decreased use over last 6 mos, painful arc, weakness. PT- no relief, injection- short term benefit. Dximpingement- surgery (+) Neer, Hawkins, painful arc, (+) SAT Decreased rot cuff strength, (+) SRT Taping, massage, dry needling- no benefit X-ray- Type 2 acromion, MRI- tendinopathy

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28 Case 4 20 y.o college pitcher, 2 mo pain (L) elbow, no acute injury, decreased velocity/ location, ball release, no swelling, no neuro sx, elbow exercises, modalities- no relief Pain medial elbow- epicondyle, ulna (+) valgus stress, (-) post med stress (-) neuro- ulnar nerve Tight GH ROM, scapula Kinetic chain deficit

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30 THANK YOU